In the second of this two-part series on “mini colonoscopies” performed using LumenEye, Sam is joined by Dr Ammara Hughes. Dr Ammara Hughes is a GP partner at Bloomsbury Surgery, Central London, and Clinical Director of Central Camden Primary Care Network. LumenEye was created by MedTech company SurgEease. Ammara explains how LumenEye is used at GP practices to diagnose conditions such as haemorrhoids and anal fissures, and how this can cut down waiting list times for both those with suspected cancer and those with lower risk.
Transcript
Sam
Welcome to Can I Butt In, the Bowel Research UK podcast where we welcome bowel cancer and bowel disease, patients, researchers, healthcare professionals and carers to butt in and share their experiences. We’re picking a topic every episode and getting to the bottom of it. I’m your host, Sam Alexandra Rose. I’m the Patient and Public Involvement Manager at Bowel Research UK, and as a patient myself, I’m excited to bring more patient and researcher voices into the spotlight.
Hello and welcome to the second episode of a two-part series on using LumenEye in what some call mini colonoscopies. Today I’m joined by Doctor Ammara Hughes, who is using this tool in the community. Dr Ammara Hughes is a GP partner at Bloomsbury surgery, central London. And clinical director of Central Camden Primary Care Network. She qualified as a doctor from Charing Cross and Westminster Medical School in 1996 and has been practising as a GP since 2003. She has been in leadership in the NHS since 2007, supporting innovation and system transformation. And as a reminder, SurgEase innovations is a pioneering UK based medical technology company that has created a point of care digital rectoscope called LumenEye. LumenEye X1 was invented by a British bowel surgeon called Fareed Iqbal and designed to improve the diagnosis and prognosis for patients with gastrointestinal diseases. So hi, Ammara, and welcome to the podcast.
Ammara
Hi, thank you for having me.
Sam
And I’ve read a little bit of a bio for you already, but do you wanna start us off just by telling us a little bit about yourself and what you do?
Ammara
Yes indeed. So I’m a GP and I have been a GP for 25 years and I’ve worked in central London for all of that time. And what my other role, which is where LumenEye comes in, is, I’m a clinical director of what’s called a primary care network. A primary care network is basically groups of practices who come together to work at population level so that we improve health outcomes for the population. And one of my roles as clinical director is to support and lead on innovations and see if we can develop services which are particularly pressing as a as a need in our local population. And that’s how this particular project came about.
Sam
Thanks for the explanation on primary care network as well, because I think it wasn’t until COVID happened that I realised, oh, some of the GPs around me are all connected because you would end up going to one of the GPs for your COVID vaccine and you think, oh, why am I not going to my normal one? It’s because they’re all in in a network together.
Ammara
Yeah, that’s right. And it’s definitely aimed at trying to bring more and more skill sets together, which you wouldn’t necessarily have just in one practice. So it’s definitely a positive thing.
Sam
Let’s dive into LumenEye and we did a previous episode with colorectal surgeon, Mr Emilio Lozano, on how he was using LumenEye in hospitals for rectal cancer. And today we’re looking at using it in the community. Do you wanna just start by sort of explaining in your words what LumenEye is? Just to remind our listeners.
Ammara
Yes, absolutely. So in general practice we were used to looking inside people’s rectums, which is the first part of the bowel because a lot of patients present with rectal bleeding or pain. And what LumenEye is, is a modern day version of something called a proctoscope, which years ago, when I first trained as a GP, we used to do quite regularly, which was examined people using this plastic device which can look inside the first sort of 10 to 12 centimetres of the rectum. And that’s really quite useful because you can identify causes of rectal bleeding without needing to refer someone into hospital. And over the years as pressures have increased as the number of appointments have increased, we have less and less time to undertake some of these procedures and as a result our population has become… Our clinical population I mean, has become deskilled at doing some of these things. And what LumenEye does is it allows us to bring this skill back into the community and what’s advantageous about this particular device. Not only can we look inside the rectum as we have been doing for years in general practice. But it allows us to take pictures. So for example, if you have people who aren’t used to looking in the bowel, for example, we’re not colorectal surgeons, but I might have my nurses, my nursing assistants. All sorts of allied health professionals using this. We can save images and if we’re not sure what we’re looking at or if we feel we have a second opinion, we can pass that on to one of our colleagues in secondary care who may not be sitting in our room with us, but who can have a direct view live of that image and advise us as to whether we need to refer that person on whether there’s anything worrying. Or whether we can safely manage it in the community.
Sam
That must bring a bit of extra peace of mind then to the patients that you’re seeing.
Ammara
Yes, absolutely. Because they’re getting care closer to home. It’s a really acceptable device. And like I say, it’s a modern day version of something that we have used in the community for a long, long time. It’s a very common thing that’s used for example, in sexual health clinics. So I’m sexual health trained and I worked in in sexual health for a year as part of my training for general practice. And it it’s very common for us to examine people’s rectums in that. But like anything for you to remain skilled and comfortable doing it and being able to treat the patient properly, you have to be doing it regularly. And that’s where this comes in at scale, because we have a few of our practitioners who have been skilled up by one of our local colorectal consultants. And it means that they are doing many, many procedures a week, which means they’ve become very skilled at looking and looking into the rectum and very skilled at using this device. So we’re very confident that what we’re now doing is a safe and effective procedure. And our colorectal colleagues have supported us very much. And getting us to that point.
Sam
That’s really good to hear and we’ll talk a little bit later as well about exactly who’s using this. But you mentioned that acceptability there as well, which is really good because and we mentioned this in the previous episode, but contrary to having a colonoscopy, you don’t need to have the horrible bowel prep drink before you have LumenEye. Or anything like that. So yeah, it’s especially. Yeah, for me for from a patient’s point of view, that is always a a bonus that you don’t need to do. You do need to an enema if I remember?
Ammara
No, we don’t need. We don’t even necessarily need an enema. For a lot of the patients that we’re seeing with rectal bleeding, which is such a common condition in general practice. Our limitation is because we haven’t been able to proctoscope them or rectoscope them, which is what the LumenEye is you end up having to refer them into secondary care where by default they would end up having a far more invasive procedure whereas. We can do something like this in the community. Because the rectum quite often isn’t full, so the rectum empties, the rectum is only full when you need to go to the toilet. Once you’ve opened your bowels on a daily basis, whatever’s normal for you, the rectum is generally empty, so you don’t actually need any bowel prep to do what we are doing in primary care, which is great. So people can turn up. As they are no prep and we’ll be able to look inside the rectum, it’s only if you need to look beyond the rectum that you need. You need to. You have some bowel preparation. So for our purposes, A suppository will do. You don’t even necessarily need to have an enema.
Sam
Right. So if somebody has rectal bleeding and they go to their GP. If the GP has LumenEye and they’re trained, can they do it right then and there and say ohh I’ll investigate now and just sort of whip it out and you’re sorted or do you need? OK, we’ll make an appointment for you. And then we’ll do it then.
Ammara
So we do it by appointment so that the key thing from a patient perspective is when you’re going in for a procedure like this, you want to have the confidence that the person doing it is skilled in doing it and has done the procedure. Either has been trained appropriately by somebody who is used to doing this. In our case the colorectal surgeon, and you also want to be able to then know what you’re, that and then be able to treat the condition that that you’re seeing. So the model that we use is we get our practices across the PCN to refer in. So my nine practices in the PCN cover about 100,000 patients, and when a patient presents to the practice with rectal bleeding, the first thing we do is we do something called a FIT test to rule out the possibility of bowel cancer because we do not want to be using this device on people that need to be fast tracked into a hospital clinic. So we follow the Nice guidelines and we make sure that where a rectal examination. So just a digital with a finger. Rectal examination is appropriate. That’s performed. The FIT test is absolutely performed in anybody with rectal bleeding these days to make sure that we rule out the likelihood of cancer once we have established that a patient is not likely to have cancer, but they continue to have rectal bleeding, the GP or whoever has seen them in in the GP practice will then refer into this clinic. And we can then book that patient an appointment and we also know from statistics of what is seen in hospital with rectal bleeding and from what we see in general practice, a lot of these patients will have haemorrhoids or an anal fissure which are easily seen with this device and we can treat in the community. Without then having to refer these people into secondary care, and the advantage of that is when a patient ends up in a clinic in secondary care, they will by default because of the protocols that are operated in colorectal clinics, they will end up with a far more invasive procedure like a colonoscopy, which is more painful, requires more bowel prep and a lot of these people will have a problem which only affects the rectum. So therefore by performing this procedure, it’s far less invasive. It saves time and space in the clinic, in the colorectal clinics and hospital for people who do need those, more tests. And it’s also giving a lot of our patients, it’s far more acceptable, less painful procedure where they don’t need to have the more invasive, painful procedure in the first place.
Sam
And what do we mean when we say that the tool is being used in the community? We’ve talked about GP’s in our previous episode. We also briefly mentioned CDC, so community diagnostic centres, is that a place where it’s been used as well?
Ammara
So in my area at the moment the only which is North Central London and as far as I’m aware we are the only people providing this service and it’s effectively a pilot at this stage. And we’re looking to evaluate it and seeing where we can expand it and whether our cancer alliance and our Integrated Care Board are willing to support us expanding, expanding the model. But a community diagnostic centre would be an ideal place for something like this because it’s easily transportable. It’s exactly where if you have the space because I’m running it out of my GP practice, we just use an ordinary consulting room. It doesn’t require much space. You just need somewhere to store the consumables and make sure that you can change the consumables. Obviously they’re disposable in between patients, so it’s an ideal thing that could be done out of a community diagnostic centre, but you just need to make sure that you’ve got the staff that are trained to do this available. But more and more. The model for us. The one that we would like to champion as a primary care network is this. This is something that can be done in a GP practice which would be ideal because it’s it saves the patient having to travel up to a CDC.
Sam
Yeah, absolutely. And yeah, my next question was going to be why is it sort of beneficial to be using LumenEye in the community? And we’ve touched on, as you said, it’s much nicer and more convenient to just be able to go to your GP for it, and I’ve got a statistic in front of me that says 60 to 70% of people who have LumenEye don’t need to be referred, and that the goal was 50% for this number.
Ammara
Yeah, that’s right. So what we were thinking was that if we saved referrals by 50% of the people that we were seeing, we thought that was that was a good result. We’re actually seeing closer to 70% of patients not needing to be referred into secondary care. And this isn’t because we can’t see, we can’t, we can’t diagnose them, but sometimes the treatment is better done in a hospital. So for example, if somebody’s got haemorrhoids which are quite are quite significant number of haemorrhoids and they’re higher up in the rectum and not low hanging, then we can’t actually treat those haemorrhoids in the community because that patient might need some anaesthetic to actually have them treated or they might need banding so the people being referred in aren’t because we have inappropriate referrals – the referrals are absolutely appropriate. But it’s just that the type of haemorrhoids that we are seeing need a more invasive treatment that we can offer in in our setting. But if you think that 7 out of 10 patients who would have gone on to a secondary care clinic are now being seen in our GP practice, that we think is a phenomenal result. And the other thing that we’ve had feedback on is I have a very diverse community where I work and culturally a lot of women prefer not to see a male clinician. So we’ve trained up one of our female clinicians to use this device. And that has been an enormous, acceptable thing for women. To come to this clinic for where they’ve refused to see a male before and they’ve refused onward referral and rather live with their symptoms or keep representing to the GP and eventually when things are intolerable, agree to a referral and then they end up on a waiting list of nearly 78 weeks so. That’s another reason why this model of in your GP practice. Knowing your local population, knowing their needs, knowing the cultural sensitivities around their health has also been an enormous benefit for setting up this in our in our primary network.
Sam
Yeah, that’s really good. And you mentioned just then about 78 week wait. That’s absolutely huge. That’s yeah, what a year and a half?
Ammara
Yes, yes. Yes. Yeah, that’s right. It’s one of the government’s targets. It’s one of the things that they measure in terms of waiting lists. And we know because this is the data we looked at that these patients, if they’re referred into a colorectal clinic, would wait for 78 weeks. And what then happens? Which is why they end up with a more invasive procedure is because the condition continues because the rectal bleeding is continuing and the GP cannot safely say, irrespective of a negative fit test, a GP cannot safely say there’s nothing harmful. There’s nothing worrying going on. A lot of those patients then end up on a cancer pathway because they simply haven’t had a commoner condition unless worrying condition ruled out because they simply don’t have the tools or the expertise to do that. So inadvertently by not having this available and by not have by having such a long waiting list. The GPs sometimes have no choice but to then refer these people on a two week pathway because they simply aren’t prepared to have that risk that this patient has an undiagnosed cancer, or something that falls outside of the tests that were available to them outside of a referral. And what that then does is it pushes the waiting lists up on the cancer pathway. Yeah. And This is why our local cancer alliance are really interested in what we’re doing because by taking some of these people off the standard waiting list, we’re also then taking some of these people off at an unnecessary 2 week. So that our hospital colleagues can concentrate on those people who really are at risk of bowel cancer and we are diagnosing and treating people with less serious conditions that can be managed safely elsewhere.
Sam
Yeah. So it’s really important for everybody then so for people who aren’t being putting down this cancer pathway, if they don’t need it, I mean that must be reassuring to people as well because if you’re being put on the pathway because the GP isn’t sure, that must be very worrying for somebody if they can’t get an answer. And then as you say, people being put onto this long waiting list and then it makes it longer for everybody. So who can use LumenEye then in terms of professionals and we’ve spoken about GP’s and what about training, is it something that takes a long time to train on? What’s interesting kind of what happens behind the curtain, what that’s like.
Ammara
Do you know what the answer to that is? Any health professional can be trained to use this so. Like I said at the beginning of this podcast, I worked in a sexual health clinic as part of my GP training before I became a GP. And this is the procedure that is done all across. And day out and anybody working in the sexual health clinic, a healthcare assistant, a nurse, a doctor, anybody can do this. And it’s really it’s a very easy, straightforward procedure. It just requires somebody being shown how to use the device, feeling comfortable using the device and knowing what they are seeing. So this is not limited to GP’s, anybody appropriately trained who is a health professional working in the primary care setting can do. Yes.
Sam
What conditions are you diagnosing in the sexual health clinic, then? Is that also haemorrhoids and fissures, or is that something else?
Ammara
In sexual health clinics, it’s generally infections, so people are coming with discharge or sometimes direct or bleeding in pain as well. But they’re a self-selecting group of patients. But the important thing there is people are seeing inflammation. They’re seeing proctitis. Which we can pick up in primary care as well. Sometimes we pick up an inflammation of the rectum which suggests they have a different diagnosis to a haemorrhoid or a fissure, or it could be infection or it could be localised inflammatory bowel disease, which comes as a potential surprise. But again, the important thing is to recognise what it is that you’re seeing and being able to treat that person appropriately or sign post them to a clinic appropriately. So This is why I say that the procedure itself is very acceptable and has been used in general practice for a long, long time. It’s just that people have deskilled doing that, partly because we don’t have time to spend with our patients because obviously we’re so overwhelmed in terms of the number of appointments that we’re offering now. So therefore if you’re not doing something, you become deskilled and therefore the patient isn’t getting that service in in the practice and that’s why our scale model is so important, because you’re taking the time and you’re using a different workforce, so it’s not impacting on our practices appointment.
Sam
I should just mention to listeners as well that you may be able to hear dogs in the background. The only regret I have is that we can’t see the dogs as it’s a podcast. But we acknowledge they’re are dogs and dogs are always awesome, so it’s really fine. What situations or patients do you specifically use LumenEye for and how do low risk patients present in terms of symptoms? Is it just bleeding?
Ammara
Rectal bleeding and anal pain. So LumenEye, the patients that we see in the clinic are patients who have had fresh rectal bleeding in whom we have done a FIT test, which is the test to rule out bowel cancer and that’s come back negative or people who have anal pain along with their rectal bleeding because a lot of those patients turn out to have a condition called an anal fissure, which is very, very easy for us to diagnose and see with the LumenEye device, so a rectoscope. And it’s also very easy to treat because we can give an ointment in in the clinic and patients really do get better in a few weeks and then we see them again and we see that their fissure was healed and it’s one of the most satisfying procedures diagnosis to make. And it’s really great for the patient as well because they go away and they get really quick relief for symptoms.
Sam
Ohh, excellent. Can you tell us a bit more about anal fissure, that isn’t something that we’ve covered in the podcast before. So what is that?
Ammara
In lay terms, it’s a cut, but because the anus is such a well supplied area with blood and nerves, it’s an area where if you do get a cut which is often through things like constipation, so passing hard stool, it’s just incredibly painful and because obviously people defecate most days, sometimes more than once a day, it’s an area that’s very difficult to get to heal, and but once you actually pick it up, giving people advice and some treatment is really, really helpful. But as with any rectal bleeding or pain, you need to be able to see the area and make that diagnosis so that you can confidently say to a patient it’s nothing to worry about and it will get better. It’s those people in whom we can’t look and can’t see an obvious cause for their bleeding or their pain. They absolutely have to be referred into secondary care because you must identify the cause in every patient.
Sam
It must be really worrying for patients as well because they don’t know why they’re bleeding. Their mind might jump to something much more serious when actually, it’s very treatable.
Ammara
Yeah, absolutely. I mean look and. And the majority of people what we talk about is persistent rectal bleeding. So rectal bleeding that’s gone on for weeks. Not something that’s just happened over a few days and stops. Obviously haemorrhoids are very, very common. So people with haemorrhoids will have rectal bleeding from time to time, but it’s those patients where the bleeding just doesn’t stop.
Sam
Sure.
Ammara
Those are the ones that come to see us, and quite rightly so, because you do need to then identify of course, a cause for the bleeding.
Sam
And we should mention as well that we’re not talking about people with IBD here, are we?
Ammara
Absolutely not, no. And those people have usually been identified through a thorough history and also another test we do, which is called a faecal calprotectin. It’s another stool test we do. And calprotectin is high in patients with suspected inflammatory bowel disease, but quite a lot of the time those patients we suspect IBD based on the history they’re giving us, which is very different from just a bit of rectal bleeding or anal pain.
Sam
So yeah, it sounds like some of these issues may not be life threatening, but they could greatly disrupt a person’s quality of life, because the pain. It makes it difficult to like, sit and work and all of that sort of stuff.
Ammara
Oh my goodness. Yes, completely. These you know in the in terms of life limiting. Of course they’re not life limiting conditions, but they are quality of life limiting conditions absolutely. And anybody who’s had an anal fissure will tell you how incredibly, awfully painful it is. Haemorrhoids as well can be so painful, particularly if they’re enlarged or they’re thrombosis. These things do affect people’s quality of life, and it’s. And. It’s brilliant to be able to help them in a way that almost eradicates their symptoms.
Sam
And thinking about those long wait times again, if something like haemorrhoids are left for a very long time, could they eventually? Do they just sort of keep getting worse? Can they lead to something more serious if they’re left untreated?
Ammara
They don’t tend to no, but they are much more they tend to be a benign condition. They don’t tend to lead to anything more serious, but the amount of bleeding and the amount of pain people get can be pretty horrendous to the point where some people do need to have them surgically treated. So if we can manage people’s haemorrhoids in the clinic and we inject the haemorrhoids under the supervision of our consultants, our health professionals running the clinic have been trained to inject mild haemorrhoids again, that gives almost instantaneous relief to patients. It’s such a good skill set to have in our armoury and it’s so safe to do in our general practice setting.
Sam
It’s really good to hear about these lower risk conditions and how they can be resolved and give people relief. And yeah, how, how LumenEye can potentially help to do that.
Ammara
The other thing to say as well, with the number of patients we are seeing at the moment. And if we continue this down this road, hopefully we’ll be able to, we’ll get funding sustained funding to continue this. There is always statistically going to be a diagnosed rectal cancer that we incidentally find with this device which wouldn’t necessarily be picked up through a FIT test. For example, the FIT test might be negative, so there is a real advantage in being able to do this in the community because we may incidentally pick up rectal cancer in the near future.
Sam
And it’s catching cancer early as well, isn’t it, because the longer somebody is on the waiting list, then it can progress and then you have less of a chance of treating it. So the earlier the better and yeah, anything that can cut that wait down.
Ammara
Exactly, exactly. And then that patient would immediately be fast tracked. So. There is that opportunistic advantage as well. You know we are we are at as much as we possibly can identifying people who we think have a low risk condition but we may be surprised but then potentially fast track somebody to an early diagnosis and save their life.
Sam
Yeah. Brilliant. I’ve just one last question for you, which is what one takeaway would you like to leave people with today?
Ammara
Ohh gosh, one takeaway message is don’t ignore your symptoms. If they’re bothering you, talk about them. Go and see your health professional and contact your GP because there may be something that we can do and it may also save your life.
Sam
Perfect. Thank you so much for coming to talk to me, Ammara.
Ammara
Thank you.
Sam
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